Clinical Check-in: Organizing the Chaos

Six Ways to Make Your Code Blue Team More Cohesive

A 60-year-old patient—who was awake and talking to her visiting daughters earlier in the day—suddenly begins to turn purple and loses consciousness. After checking for a pulse, the patient’s nurse determines the patient is in cardiac or respiratory arrest and calls a code blue. An alert goes out over the public address system, and a team of critical care professionals from across the hospital springs into action. An ICU physician, anesthesiologist, two critical care nurses and a respiratory therapist rush in to begin resuscitative efforts, shocking the patient with an automated external defibrillator and giving her a shot of epinephrine. The patient is successfully resuscitated, and everyone breathes a sigh of relief.

Though it sounds like an episode of a TV medical drama, code blue scenes like this are something every hospital needs to be prepared for. In real life, it can be challenging to coordinate a rapid, organized response involving a divergent team in the midst of tumultuous circumstances. But creating a well-oiled code blue machine can—and does—save lives. “A code blue is a very chaotic time,” says Beverly Shields, RN, MSN, CCRN, director of critical care and medical-surgical services at Franklin, Tennessee-based Community Health Systems. “Facilities should be able to expect organized, yet controlled chaos. It just takes a lot of preparation and practice.”

Ready to make your code blues run more smoothly? Follow these guidelines:
1. Look to the leader. While each member of the interdisciplinary team has the requisite skills to care for the patient, code blue team members are typically unaccustomed to working with each other. That’s why one of the most important ways that facilities can prepare for emergency situations is to designate which person will be the leader when a code occurs, Shields says, and make sure that person is assertive enough to command the attention of the team. In many cases, the emergency physician or ICU physician who is present at the time will take charge—but it’s crucial to ensure that everyone knows the drill upfront.

A board member of the American Academy of Emergency Medicine (AAEM), Andy Walker, M.D., is semiretired and now practices emergency medicine in a locum tenens role. He frequently doesn’t know the nurses or respiratory techs when he responds to a code on an inpatient unit, but as the emergency physician on duty, he sees it as crucial to take control and firmly assert himself as the code leader. “The rest of the team needs a leader, so I identify myself clearly and loudly when I enter the room,” Walker says. “I want to gather some background information as quickly as possible, so I simply ask, ‘What’s the story?’” While Walker has rarely found team cohesion to be a problem, challenges occasionally emerge that keep the code from running as smoothly as possible. In those cases, “the leader must quickly remedy the situation,” he says. “Sometimes the room is too crowded and noisy due to bystanders who have no role in the code, so I ask those without a code-related job to leave. Or someone who does have a code-related job is talking constantly and loudly, and I have to kindly ask that person to quiet down. If I am about to bring in a member of the patient’s family, I remind team members to be circumspect about their comments and behavior.”

2. Define roles and delegate. Think through the different tasks that must be done for a successful code blue and assign each one to a specific professional. “Designate who will be responsible for making sure the defibrillator is turned on and who will do the charting,” Shields says. “Those things need to be decided before you ever have a code.” Each member of the team provides a different perspective and skill set that other team members should be aware of, so everyone knows what to expect. “Having predetermined, well-defined roles adds efficiency to the process,” says Laura Reed, MSN, RN, CCRN, vice president of critical care and neuro services at Reston Hospital Center in Reston, Virginia. “In reality, we are able to hold one another accountable to be sure there are no gaps in the care and treatment of the patient.”

3. Seek standardization. Look for ways to standardize your team’s reaction to codes, says Tom Tobin, M.D., an emergency medicine physician and at-large physician director of AAEM. “Not all codes are the same, but limiting variation as much as possible will make the teams more effective. Similar to airline flight crews, two pilots who have never flown together can deal with significant malfunctions due to standardization of their responses and clear hierarchy. Unlike the mechanics of airplanes, humans have many more variations, so the standardization is more difficult and in some instances impossible. However, that doesn’t mean we shouldn’t apply those tools where applicable and practical.”

It makes sense to help code blue team members rapidly access key pieces of the patient’s medical history or condition, for example. “Too many times there is a significant delay in care because someone has to search through the medical chart to get key pieces of information,” Tobin says. “It was difficult with paper charts and now it is even more difficult and time-consuming with electronic health records (EHR). Access to a cheat sheet of key patient data—whether on paper or within an EHR—is critical. EHRs should have a screenshot showing the key pieces of information needed during a code blue.”

4. Schedule ongoing training. Code blue teams should regularly train and perform drills to ensure they are prepared for the real thing. “You play like you practice,” Reed says. “We do mock codes regularly with the expectation that each team member will participate as if it were real. Even though you may never work with some of the members of the mock team in an actual code, we all learn what to expect from one another. That experience gets translated into good performance during actual events.” Reston Hospital Center holds a mock code blue every other month. In the months in between, the hospital alternates practicing more diagnosis-specific codes, such as ones involving STEMIs (ST-segment elevation myocardial infarctions). While patient outcomes are positive, the teams are working toward increasing timeliness and efficiency.

5. Take advantage of technology. Innovative technologies continue to provide new ways of coordinating code teams and ensuring their effectiveness. At Reston Hospital Center, each code blue team member carries a corporate-issued mobile phone that sends alerts via text messaging whenever a code is called, Reed says. That provides a means to track response time. Technology can also be used to evaluate the effectiveness of each code blue or mock code blue. For instance, some CHS facilities have defibrillators that, after use, provide instant reports on the effectiveness of chest compressions, Shields says.

6. Cement the lesson. The ideal time to process learning and prepare for the next code blue event is right after the last one. “Postcode debriefing is one of the most important steps,” Shields says. “A debriefing should include everyone who was involved in the code discussing what went well and what didn’t, and what each individual should work on. It’s vital for continual improvement.” About a year ago, Reston Hospital initiated a formal debriefing after each code blue. It is overseen by a nursing supervisor—a fixed role during such events—using a form or script. The script was recently revised to check and make sure the team followed the algorithms for advanced cardiac life support. And, the instructions for how to print a code summary from the monitor/defibrillator are included on the back of each debriefing form. “The summary was being forgotten, but it provides valuable information regarding the patient’s heart rhythm and events that occurred during the code,” Reed explains. Team members are encouraged to offer feedback during debriefings. “The process is meant to be nonpunitive and a learning opportunity,” Reed says. “We attach the debriefing form to each code documentation form. Having a formal debrief with a checklist ensures we are gathering this valuable information and learning from it.”